Beyond appearances

(Washington Post) -- Four years ago, Marna Palmer was an active James Madison University freshman. The Woodbridge native was 6 feet tall, thin and athletic. But the pressure of starting college got to her. She began bingeing and purging -- overeating and then vomiting, a condition known as bulimia.

Palmer has received counseling and takes antidepressants to reduce her weight obsession. She now understands that her disease was as much about gaining control of her life as it was about maintaining an ideal body weight.

"This was just a way to get control of transitioning to college and everything," said Palmer, now 22 and a graduate of the university. "[Bulimia] is my self-defense mechanism. . . . It's taken care of me. It's like this best friend that you have, but at the same time it's your worst enemy."

Actress Mary-Kate Olsen, 18, reportedly is being treated for anorexia nervosa, a similar eating disorder characterized by eating so little that one's health and even life are put at risk. She and her twin sister, Ashley, will start school at New York University this fall, according to published reports.

From a distance, it's easy to assume that the social pressure to have a perfect body, exaggerated by the spotlight of Hollywood, is the cause of Olsen's problems. But as Palmer's case shows, eating disorders can be more complex in origin. Being unhappy with one's body is only part of the story.

"All the research suggests that the most common indicator [of eating disorders] is body dissatisfaction," said Ohio State University professor Tracy Tylka. "But a lot of women have body dissatisfaction, and not a whole lot of women have eating disorders."

Researchers have not established a universal definition or measure of body dissatisfaction. "It's a concept that I think most people are familiar with, and you can measure it in different ways," said David M. Garner, a psychologist, researcher and eating disorders clinician. Neither government nor academic sources publish statistics specifically on body dissatisfaction. But a 1997 survey of 4,000 readers of Psychology Today, conducted by Garner, reported that 56 percent of the female respondents were unhappy with their overall appearance, and 66 percent said they were unhappy with their body weight. Yet anorexia affects 0.5 to 3.7 percent of women, according to the National Institute of Mental Health (NIMH). About 1 to 4 percent of women have bulimia.

Women are more likely than men to develop eating disorders. Men make up about 5 to 15 percent of those with anorexia and bulimia, and about 35 percent of those with binge-eating disorder (characterized by excessive eating that occurs, on average, at least two days a week in a six-month period, according to NIMH).

In a study published in April in the Journal of Counseling Psychology, Tylka looked into other factors that may co-exist with eating disorders. The research surveyed two sets of about 300 midwestern female college students aged 17 to 58. It looked at whether such issues as social insecurity, poor impulse regulation, appearance control beliefs and neuroticism intensify eating disorder symptoms.

The results identified body surveillance -- the constant examining of oneself in the mirror and thinking about how others perceive you -- as the factor that, when combined with body dissatisfaction, heightened eating disorder symptoms the most.

The results were surprising, Tylka said.

"I expected [the study to demonstrate that] women who couldn't regulate their impulses, that perhaps they . . . decided to use food to regulate their emotions," she said in a phone interview. But poor impulse regulation turned out not to be a statistically significant factor. Having a family member or friend with an eating disorder was.

Still, it was body surveillance that topped the list. Participants responded to eight questions about the "degree to which a woman watches her body and thinks of . . . [it] in terms of how it appears to others rather than how it feels or functions," the study reported. Respondents ranked the statements according to how much they applied to their lives -- from one (strongly disagree), to seven (strongly agree).

Other researchers continue to explore factors that may lead to eating disorders.

St. Joseph Medical Center's Center for Eating Disorders in Towson, Md., is taking part in a five-year, $10 million effort funded by NIMH. Eleven groups of researchers in the United States, Canada and Europe hope to enroll about 400 families.

The families need to have at least two people with anorexia, said Harry Brandt, head of the psychiatry department at St. Joseph and a lead investigator in this study. The participants will receive "a complex genetic analysis to determine whether there's any genetic abnormality that might predispose people to anorexia nervosa." Mothers and daughters cannot enroll together because their DNA is too similar, Brandt said

An earlier study conducted by Switzerland's Price Foundation showed a possible chromosomal abnormality in people with anorexia nervosa, which sparked interest in pursuing the current research, said Cynthia M. Bulik, a psychiatry professor at the University of North Carolina at Chapel Hill who is working on the NIMH study.

Tylka noted that in those with eating disorders, the desire to maintain an ideal body image leads to "poor interceptive awareness" -- or being out of touch with internal feelings and sensations.

"They constantly think about how they look and ignore their internal guide to tell them when they're hungry," Tylka said.

Palmer said that at one point -- when she was compulsively exercising -- she was so focused on staying thin that she ignored pain from an injury. Running seven miles a day and working out too much resulted in her hurting her right leg, she said. The pain persisted for nearly a week before she slowed down.

"Some days I'd go to the gym four times a day," Palmer said. "I always saw exercise as something I had to do. I never thought of it as something that I enjoyed."

Now, through group and individual counseling, Palmer understands how her desire to control her changing life contributed to her eating disorder.

"My friends would say, 'Well, why don't you just stop?' " she said. "But it's just not that easy."